State of the Sciences: Research Updates from the IAS Leadership Tuesday, December 8, 2015 Johns Hopkins Bloomberg School of Public Health

1. Anton Pozniak
Consultant Physician
Director of HIV Services
Chelsea and Westminster Hospital, London
The Test and Treat Approach
Achieving 90-90-90

2. Vatican Test & Treat Initiative Shinyanga
and Simiyu , Tanzania
A collaboration
Shinyanga Diocese, Vatican, SSAT,CUAMM, AIGHD, Gilead

3. Shinyanga /Simiyu demographics
3
[1]
http://www.geohive.com/cntry/tanzania.aspx (census 2012)
• Population 1,534,808
• Three districts, 5 councils
• Also will cover Simiyu
population of 1,584,147
Shinyanga is a poor area, despite
relatively thriving mining industry
HIV prevalence Shinyanga (8.5%)
appears to be higher than national
figure (5.7%)
Tanzania has strong government MOH
involvement in HIV programs

4. Project Objectives and Specific
Aims

5. How will this be achieved?
• First some Background to the Global problems
• Then some plans going forward

6. 2015 an amazing target achieved

7. GLOBAL MORTALITY AND INCIDENCE DECREASED….

8. 5,600 new
HIV
infections
each day
Despite impressive progress with prevention, the
spread of HIV has yet to be controlled!
Source: UNAIDS Global Report 2014
In 2014, worldwide there were:
1.2 million HIV deaths
36.9 million living with HIV
2.0 million new infections
2.0 million put on treatment

9. “The AIDS response is at a crucial juncture, both in
its immediate trajectory and its sustainability…”
Ambitious Fast-Track targets Maintaining 2013 levels of coverage
Number of
new HIV
Infections
in LMICs
(millions)
2.5 million
0
2010 2015 2020 2025 2030
2.5 million
2.1 million
200,000
Window of
opportunity
Source: Adapted from UNAIDS Fast-track Report
Total HIV
infections
averted
2015-2030
28
Million

10. Note: PMTCT, Screening transfusions, Universal precautions, etc. have not been included
Behavioural
Intervention
HIV Counselling
and Testing
Coates T, Lancet 2000
Sweat M, Lancet 2011
Male Condoms
Female Condoms
Treatment of
STIs
Grosskurth H, Lancet 2000
Male
circumcision
Auvert B, PloS Med 2005
Gray R, Lancet 2007
Bailey R, Lancet 2007
Treatment for
prevention
Cohen M, NEJM, 2011
Donnell D, Lancet 2010
Tanser, Science 2013
Needle
Exchange
Drucker E, AIDS 1998
Oral pre-exposure
prophylaxis
Opioid substitution
therapy
Mathers BM, Lancet 2010
HIV
PREVENTION
Grant R, NEJM 2010 (MSM)
Baeten J , NEJM 2012 (Couples)
Thigpen M, NEJM 2012 (Heterosexuals)
Choopanya K, Lancet 2013 (IDU)
Microbicides
for women
Abdool Karim Q, Science 2010

11. We already knew that ART can reduce the risk of new infections
11
96% reduced
risk of new
infection
HPTN 052 study
New infections amongst sero-discordant
couples

12. 12
53% reduced
risk of serious
illness or
death
START trial
Instances of AIDS, serious non-AIDS events or death
Now we have strong evidence that early initiation significantly
improves patient outcomes

13. New
eligibility criteria: treatm
ent
can
be started
irrespective of CD4

14. The Impact of TasP
New HIV infections (% growth) versus ART coverage in 51 countries
Hill et al. World AIDS Conference, July 2014, Melbourne, Australia [LBPE29]
14
Incidence(%)
14
70
12
10
8
6
4
2
0
6050403020100
ART (%)

16. ACHIEVING 90:90:90:
• The Goal

17. 90 90 90: THE UNAIDS STRATEGY TO FURTHER
CURB THE HIV EPIDEMIC
based on expanded access to treatment and on the “treatment as
prevention” concept
90%
of all people
living with HIV
will know their
HIV status
90%
of all people
diagnosed with
HIV will receive
sustained
antiretroviral
therapy.
90%
of all people
receiving
antiretroviral
therapy will have
durable
suppression.

18. Global Estimates (2014-15) vs the Gap
to reach 90-90-90 Targets
Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015. * Average viral
suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic
review." Bulletin of the World Health Organization 91.5 (2013): 377-385.
Breakpoint 1:
13.4 million
Undiagnosed Breakpoint 2:
14.9 million
not treated
Breakpoint
3:
15.3 million
Not Virally
Supressed

19. Cascade of HIV care – Kenya 2012 (+15)

20. ACHIEVING 90:90:90:
A GLOBAL GAME CHANGER FOR PUBLIC HEALTH
• Addressing the barriers

21. ACHIEVING 90:90:90:
A GLOBAL GAME CHANGER FOR PUBLIC HEALTH
•Addressing the barriers
– HIV testing
– Late presentation
– Low ART coverage
– Retention in care
– Retention in ART
– Financing
– Human rights
– Stigma

22. Testing challenges
•Policies and laws
•Stigma and
discrimination
•Delivery

23. Discriminatory Laws and Policies
Percentage countries whose laws, regulations, or policies can hinder
service provision for key populations
23
53% 47% 43%
Sex Workers MSM PWID
MSM, men who have sex with men; PWID, people who inject drugs
Source: GARPR 2013 – “Countries reporting existence of laws, regulations or policies that can pose
obstacles to effective HIV prevention, treatment, care and support services for key populations”

24. 17.1 million people
living with HIV do not
know their HIV status

26. A way forward: HIV self-
testing• Available since 1990s
• UNAIDS policy since 2004
• Private non-medical affair
• Convenience and comfort with
instant robust results
• Circumvent barriers
• Preferred modality
• heterosexual men, young
people, health workers in high
prevalence settings, and key
populations

27. Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015. * Average viral
suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic
review." Bulletin of the World Health Organization 91.5 (2013): 377-385.
Breakpoint 1:
13.4 million
Undiagnosed Breakpoint 2:
14.9 million
not treated
Breakpoint
3:
15.3 million
Not Virally
Supressed
The second “90”

28. Antiretroviral treatment coverage
is still very low in many regions

29. Starting patients on ART is
just the first step….
…..retaining people in therapy and
keep the virus fully suppressed
(for years) is far more
complicated….

30. Retention in HIV care programmes
gender
WHO clinical stage
age at start of ART
CD4 count
Global analysis of retention in care in
initial HIV care and treatment program
in the IeDEA regions (41 countries)
WHO-IeDEA collaboration, 2015

31. The new ART eligibility criteria will increase the proportion of asymptomatic
patients in ART programs.
As they are still well, these patients may perceive no short-term benefit from
entering treatment, with consequent ART cessation,
Especially in the face of onerous ART procurement or regimens with persistent
side effects.
“ Why shall I take this pill every day if I am feeling well “ ?
“ Yes, I stopped my medication because I feel better and think I am cured”

33. Simplification of ART delivery,
At least for asymptomatic and clinically stable patients,
We will take the drugs to the patient !
Full community-based care models,
Basis clinic activities –BP urine test drug delivery
Including motivational counseling and HIV infection literacy
programs
Run by trained community health workers supported by
a nurse
Innovative models of HIV care are
needed

34. Community-based Adherence Clubs (CACs)
From June 2012 to December 2013:
‒ 74 CACs were established
• Each with 25–30 patients
• Provided ART to 2,133 patients
• Met every 8 weeks
‒ CAC patients were predominantly female (71%) and lived within
3 km of the facility (70%)
‒ 9 patients in a CAC died (0.1%)
‒ 53 were up-referred for clinical complications (0.3%)
‒ 573 CAC patients sent a buddy to collect medicines at least one
visit (27%)
After 12 months in a CAC:
‒ 6% of patients were lost to follow-up
‒ Fewer than 2% of patients retained experienced viral rebound
34Grimsrud A et al. Journal of the International AIDS Society 2015, 18:19984

35. Need Regimens with minimal side effects
WHO goes in the right direction…..

36. Facility-based Care Community-based Care Main effect
EFV-based regimen Interaction effect: 65% Interaction effect: 75% EFV-based regimen: 70%
DTG-based regimen Interaction effect: 75% Interaction effect: 90% DTG-based regimen :
82,5%
Main effect Facility- based care: 70% Community-based care:
82,5%
Combining Goal 2 and 3 of 90-90-90
ART RETENTION TRIAL
Improving retention in care and adherence to ART of asymptomatic HIV+ patients: a
factorial, randomized trial exploring the interaction of two interventions:
a community-based HIV-care model combined with a more tolerable first line regimen.
(SA, Zimbabwe, Zambia, Rwanda, Ethiopia, UK, Italy)

37. Money-Moving towards end of AIDS:
main results and new ambitious targets…
Key parameters 2005 2015 2020 2030
New HIV infections 3 million 2 million 500,000 200,000
AIDS-associated
deaths
2.4 million 1.2 million 500,000 400,000
PLHIV accessing ART 1.5 million 15 million 30 million ALL
Investments for global
HIV response (US$)
7 billion 20 billion 32 billion 29 billion
WHO & UNAIDS reports , 2014 & 2015

38. *In generic accessible countries. Source: CHAI - The State of the Antiretroviral Drug Market in Low- and Middle-Income Countries , ISSUE 5, December 2014
38
1
2
3
we expect those costs to keep going down as a result of three key
factors

39. 39
Investment made,
limited/no impact
Missed
opportunity to
have impact
TESTED
PLWHIV
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
Losses in
testing
Losses in testing,
linkage and care
Losses in testing,
linkage,
care and
treatment
$$$$$$$$$$$$$$$$$$$$$$$$$LINKED
ON ART
SUPPRESSE
D
$$$$$$$$$$$$$$$$$$$$$$$$$
Ongoing infections, morbidity and mortality
Max. return on
investment
Illustrative
We need to make sure we get the most of the investment, since at
present we are losing a lot of the gains through poor retention

40. 90 90 90 – Conclusions
• The 90 90 90 targets are achievable in many countries
• Treatment as Prevention is definitely part of the solution
• The whole treatment cascade shall be supported.
• Existing barries shall be addressed:
– Expand testing through innovative strategies
– Stigma is addressed
– Innovative models of caring
– Community involvement is extended (and supported)
– The focusi is on Key Affected Populations
– Donor support expands
– Governments tackle stigma, discrimination and protect human rights
– Research on better medicines, and towards a vaccine and a cure shall
continues to make progress
40